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HomeMy WebLinkAbout1530A /�, n�pr p�}►� �j,�p , WORKERS'COMPENSAiION DEClARAfiOM �� APPLIC����� rVR PLUlY{D�f\i�3��n/Y1���; � � ' I hereby offirm that i have o<er�iEimte of consent lo nel! 20-0�26 DPW 6l87 ; � - ;' .^' : � inwre,or o cerlificate ot Wo�kars'Compensotion Insuronce, 76A667A � �`- �'� or a certified to�pys th1ereof(y`ec 3800,l C. r /� . COUNTY OF LOS ANGELES DEPT.OF.PUBUC WORKS P�olity No�d����"" "Compony �tr���' � Cerlified copy is hereby furnished. BUILDiNG FOK APPLICANT TO FILL W(P{tINT OR TYPE) ADDRE55 i d z3 J�i U✓� Certified copy is filed with the cov ry building insp ` � iond�epsa�r�m,enf. ri1MBER fl%TUREORITEM � fEE ���rcY �,�.,F�+���r Do1C�Sl�Appli nt WATERUOSEl NEAREST CERTIFICASE OF E MP qN FROM WORKERS' � BATM TUB CROSS ST. COMPE N INSURANCE � SHOWER OWNER d�)���? (Thi��«fion no�d not � eompbbd.H t6o wark Inrolvad 6y Mpq Ih�p�r�wN Fs for on�lwndred aellari(31DOf or I��a.) �_ LqVqTORY A��RE55 ' I cerfify 1M�at in the performonce of the wark far which this ��Ty TEt.NO. � psrmil is issued,f sho11 nof employ any person in any monner SINK so aa to become subject�o rhe Worker' ompenaotion la . � DISMWASHER COMRACTOR ps C�yt i QOlNES WASHFR �� j Daie � pplt[ ADDIiE55 NOTICE TO APPIICANT: ! af r making this eriifica�e of SWIMMINGPOOLRECEPiOR � E■emption, you sho�l b ome sub'�ect to the Workers' - CITY � �^Q,. TEL N0. ��� � Compensaffon provis�o the Labor Coda,you muif fofth- UWNSPRINKLERSYSTEM with Comply wilh suc pravisions or this permit shall be STAT � � IIC. Y LICENSE NO. � C1A55 de�med revoked. � ' WA7FRHEATER � tICENSEO CONTRACTORS QECLARATIQN OISTRiCt NO. ESSED BY � I heroby offirm thpf 1 am�iCanaed under provieions of Chapter 9 GAS 5YSSEM OUFlETS ��_ � (commencing with S�ction 7000)of 6ivision 3 of!he B�aine�s - OUnEf50VER } ' and Profeuions Code,and my license'rs in full force and effect. � 5 PE 5YS1EM FINAI YALIOATION LL' � oYG� onTe � � License N�mber lic,Clas� FlNAL � Controctor � �'��� Date �9 Z' � BY O ' Q V ! '� 4 om exempt under Sec. a Y 8.8P.C.for�his reoson p{an cheGk fee oa�Q. �t 5 3 Q A � _ PLUM8ING PERMIT ISSUING FEE$ #� �. • �rj � SigtwWra � �� �� � TOTAL FEE � � Plan check applicant . i SINGIE FAMILV `I+t 4 6 5 p ! HOME OWNFR-BUIl6ER UECLARATION Pk�me � ����S 9= q I hmeby offirm that l am exempt from�he Controctor's Litense � " Law for the following reoson(Seclion 7037.5, Business ond Address ��t ��$9 ` Professions Code): Ciry Tel.No. ❑ I,as owner oi the properry,will do ihe work ond�he 4 � 1 str�dure ia not intendad or offered for sale �SeUion i 7044,Business and Professions Codej. I CONSTRUCTION IENDING AGENCY i I hereby affirm that there i:a mnstruction lending agency for � the performance of the work for which rhis permir is issued (Sec 3097,Civ.C.). � ; I Lender's hlame I Lender a Address � 1 cerlify that 1 hove read lhis appl�cafion and state fhol�he � obove informafion ia corrett.I agree�o tomply with all County ordinances and Staie fows reguVoting Pl�mbin9,ond he�eby ou�honze repre�enlatives of ihis County to eNer upon the � � + a6ov eMiOned p�opBrty for inspeCtion purposes. � r2 SEE REVERSE fOR EXPIAFlATORY LANGUAGE � Signature of Permi ee Dote �1 ' I �.r_ �; � � i � ` '[: �` ` y,� C U .... ^q 4 i I � � "� i V, � �' '� _ p.' t: � C � C: Lw'l v y .� C.L. ' I � •�;�~S �:�•C c ��•[3. ��+ O� U V Q O «. � ,;•+��'- � � . I i . S'_' G. 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